ST-segment Elevation Myocardial Infarction Presenting Research Articles

Day-night pattern of acute ST-segment elevation myocardial infarction onset in patients with obstructive sleep apnea.

Obstructive sleep apnea (OSA) is associated with acute nocturnal hemodynamic and neurohormonal abnormalities that may increase the risk of coronary events, especially during the nighttime. This study sought to investigate the day-night pattern of acute ST-segment elevation myocardial infarction (STEMI) onset in patients with OSA and its impact on cardiovascular adverse events. We prospectively enrolled 397 patients with STEMI, for which the time of onset of chest pain was clearly identified. All participants were categorized into non-OSA (n = 280) and OSA (n = 117) groups. The association between STEMI onset time and major adverse cardiovascular and cerebrovascular events was estimated by Cox proportional hazards regression. STEMI onset occurred from midnight to 5:59 am in 33% of patients with OSA, as compared with 15% in non-OSA patients (P < .01). For individuals with OSA, the relative risk of STEMI from midnight to 5:59 am was 2.717 [95% confidence interval (CI) 1.616 - 4.568] compared with non-OSA patients. After a median of 2.89 ± 0.78 years follow-up, symptom onset time was found to be significantly associated with risk of major adverse cardiovascular and cerebrovascular events in patients with OSA, while there was no significant association observed in non-OSA patients. Compared with STEMI presenting during noon to 5:59 pm, the hazard ratios for major adverse cardiovascular and cerebrovascular events in patients with OSA were 4.683 (95% CI 2.024 - 21.409, P = .027) for midnight to 5:59 am and 6.964 (95% CI 1.379 - 35.169, P = .019) for 6 pm to midnight, whereas the hazard ratios for non-OSA patients were 1.053 (95% CI 0.394 - 2.813, P = .917) for midnight to 5:59 am and 0.745 (95% CI 0.278 - 1.995, P = .558) for 6 pm to midnight. Patients with OSA exhibited a peak incidence of STEMI between midnight and 5:59 am, which showed an independent association with cardiovascular adverse events. Wang Y, Buayiximu K, Zhu T, etal. Day-night pattern of acute ST-segment elevation myocardial infarction onset in patients with obstructive sleep apnea. J Clin Sleep Med. 2024;20(5):765-775.

Characteristics, Treatment, and In-Hospital Outcomes of Older Patients With STEMI Without Standard Modifiable Risk Factors

BackgroundStrategies targeting standard modifiable cardiovascular risk factors (SMuRFs), including hypertension, diabetes, hypercholesterolemia, and smoking, have been well established to prevent coronary heart disease. However, few studies have evaluated the management and outcomes of older patients without SMuRFs after myocardial infarction. ObjectivesThe authors sought to evaluate the profile of patients with ST-segment elevation myocardial infarction (STEMI) aged ≥75 years without SMuRFs. MethodsThis study is based on the CCC-ACS (Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome) project. Patients aged ≥75 years with a first presentation of STEMI were enrolled in this study between November 2014 and December 2019. Modified Poisson regression was used to evaluate the association between SMuRF-less and in-hospital outcomes. ResultsAmong 10,775 patients with STEMI aged ≥75 years, 1,633 (15.16%) had no SMuRFs. Compared with those with SMuRF, SMuRF-less patients received less evidence-based treatment. In-hospital mortality was similar among patients with and without SMuRFs (5.44% vs 5.14%; P = 0.630). However, after adjustment for patient characteristics and treatment, being SMuRF-less was significantly associated with a reduced risk of mortality (RR: 0.80; 95% CI: 0.65-0.99; P = 0.043). SMuRF-less patients also had a significantly reduced risk of in-hospital death when only adjusting for in-hospital treatment (RR: 0.78; 95% CI: 0.63–0.98; P = 0.030), regardless of patient characteristics. ConclusionsApproximately 1 in 7 STEMI patients in China ≥75 years old had no SMuRFs. The similar mortality in patients with and without SMuRF can be partially explained by the inadequate in-hospital treatment of SMuRF-less patients. The quality of care for older patients without SMuRF should be improved. (CCC Project–Acture Coronary Syndrome; NCT02306616)

Mortality in ST-Segment Elevation Myocardial Infarction With Nonobstructive Coronary Arteries and Mimickers

The clinical characteristics and prognosis of patients with ST-segment elevation myocardial infarction (STEMI) with nonobstructive coronaries (MINOCA) are largely unknown. To assess differences in 5-year mortality in patients presenting with STEMI due to MINOCA and MINOCA mimickers as compared with obstructive disease. A retrospective analysis of a prospective registry-based cohort study of consecutive STEMI activations at 3 regional Midwest STEMI programs. STEMI without a culprit artery and elevated troponin levels were categorized as MINOCA (absence of coronary artery stenosis >50% and confirmed or suspected coronary artery plaque disruption, epicardial coronary spasm, or coronary embolism/thrombosis) or MINOCA mimickers (takotsubo cardiomyopathy, myocarditis, or nonischemic cardiomyopathy). Data were analyzed from March 2003 to December 2020. Adjusted Cox regression analysis was used to assess 5-year mortality risk in STEMI presenting with MINOCA and MINOCA mimickers in comparison with obstructive disease. Among 8560 consecutive patients with STEMI, mean (SD) age was 62 (14) years, 30% were female (2609 participants), and 94% were non-Hispanic White (4358 participants). The cohort included 8151 patients with STEMI due to obstructive disease (95.2%), 120 patients with MINOCA (1.4%), and 289 patients with MINOCA mimickers (3.8%). Patients were followed up for a median (IQR) of 7.1 (3.6-10.7) years. Patients with MINOCA and MINOCA mimickers were less likely to be discharged with cardiac medications compared with obstructive disease. At 5-year follow-up, mortality in STEMI presenting with obstructive disease (1228 participants [16%]) was similar to MINOCA (20 participants [18%]; χ21 = 1.1; log-rank P = .29) and MINOCA mimickers (52 participants [18%]; χ21 = 2.3; log-rank P = .13). In adjusted Cox regression analysis compared with obstructive disease, the 5-year mortality hazard risk was 1.93 times higher in MINOCA (95% CI, 1.06-3.53) and similar in MINOCA mimickers (HR, 1.08; 95% CI, 0.79-1.49). In this large multicenter cohort study of consecutive clinical patients with STEMI, presenting with MINOCA was associated with a higher risk of mortality than obstructive disease; the risk of mortality was similar in patients with MINOCA mimickers and obstructive disease. Further investigation is necessary to understand the pathophysiologic mechanisms involved in this high-risk STEMI population.

A pilot randomized controlled trial of novel reperfusion method in patients of acute st elevation myocardial infarction during primary percutaneous coronary intervention

Abstract Objectives This study was conducted to explore the feasibility, clinical safety and potential effects of a novel reperfusion method, Volume-Controlled Reperfusion (VCR) in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Background Reperfusion injury is associated with larger infarct size (IS) and drawback of long-term overcome. Microvascular obstruction (MVO) as detected on late gadolinium-enhanced cardiovascular magnetic resonance (LGE-CMR) is the most used index for assessment of reperfusion injury. To date, there is no feasible gradual reperfusion method in primary PCI setting. VCR is an original reperfusion method feasible in primary PCI for both accurate gradual reperfusion and intermittent flow. Methods A total of 60 patients with STEMI presenting within 12 h of symptom onset undergoing PPCI were randomized enrolled, 30 patients in VCR group and 30 patients in control group with routine PCI only. VCR was performed with the dual catheter technique, 10ml of artery blood diluted with10ml of heparin saline infused via manual aspiration catheter at speed of 20ml/min for 10 rounds after suspending the antegrade flow using a prophylactic inflated balloon. Then, routine PCI procedure as usual. The primary endpoint was major adverse cardiac events (MACE) during hospitalization, the main second endpoint was the MVO extent difference measured on day 5-7 post-procedure. Results Baseline characteristics were well matched between two groups. No major adverse cardiac events (MACE) found in-hospital or 30 days followed up. There were no complications associated with VCR procedure. 43 patients had LGE-CMR exam (22 in Control group, 21 in VCR group, among them, 14/22 were anterior wall control and 14/21 VCR). There was no significant difference in infarct size, MVO or CMR-LVEF in total patients between VCR and control. However, significant difference in CMR-LVEF was noted between control and VCR anterior wall subgroup (40.53 ± 7.39 vs50.55 ± 7.55; P=0.002), the average of MVO and MVO of infarct size were smaller in VCR group while no significant difference. Conclusions This is the pilot RCT study showed VCR method was feasibility and clinical safe among patients with acute STEMI during PPCI and 30 days followed up, indicated potential attenuate effect in reperfusion injury as well. Staged II study is needed to verify clinical benefit.VCR illustrationLGE-CMR figure

Tenecteplase: A Review of Its Pharmacology and Uses.

Tenecteplase: A Review of Its Pharmacology and Uses.

Reperfusion Delays and Outcomes Among Patients With ST-Segment-Elevation Myocardial Infarction With and Without Cardiogenic Shock.

Mortality remains high in patients with ST-segment-elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS), and early reperfusion has been shown to improve outcomes. We analyzed the association between first medical contact (FMC)-to-percutaneous coronary angiography time with mortality and major adverse cardiovascular events among patients with STEMI with and without CS. We performed a retrospective analysis of the Vancouver Coastal Health Authority STEMI registry, including all patients with STEMI who received primary percutaneous coronary angiography between January 1, 2010, and December 31, 2020, and stratified them by presence or absence of CS at hospital arrival. The primary outcome was in-hospital mortality, the secondary outcome was in-hospital major adverse cardiovascular events, defined as a composite of the first occurrence of mortality, cardiac arrest, heart failure, intracerebral hemorrhage, cerebrovascular accident, or reinfarction. Mixed effects logistic regression with restricted cubic splines was used to estimate the relationships between FMC-to-device time and the outcomes in the CS and non-CS groups. 2929 patients were included, 9.4% (n=275) had CS. Median FMC-to-device time was 113.5 (interquartile range, 93.0-145.0) and 103.0 (interquartile range, 85.0-130.0) minutes for patients with CS and without CS, respectively. More patients with CS had FMC-to-device times above guideline recommendations (76.6% versus 54.1%, P<0.001). Between 60 and 90 minutes, for each 10-minute increase in FMC-to-device time, absolute mortality for patients with CS increased by 4% to 7%, whereas for patients without CS, it increased by <0.5%. Among patients with STEMI undergoing primary percutaneous coronary angiography, reperfusion delays among patients with CS are associated with significantly worse outcomes. Strategies to reduce FMC-to-device times for patients with STEMI presenting with CS are required.

Lipoprotein associated- phospholipase A2 in STEMI vs. NSTE-ACS patients: a marker of cardiovascular atherosclerotic risk rather than thrombosis.

A consecutive cohort of patients undergoing coronary angiography for acute coronary syndrome (ACS) were included and divided according to presentation for non ST-segment elevation-ACS or ST-segment elevation Myocardial Infarction (STEMI). Lp-PLA2 activity was assessed in blood samples drawn at admission using the Diazyme Lp-PlA2 Activity Assay. We included in our study 117 patients, of whom 31 (26.5%) presented with STEMI. STEMI patients were significantly younger (p = 0.05), displayed a lower rate of hypertension (p = 0.002), previous MI (p = 0.001) and PCI (p = 0.01) and used less frequently statins (p = 0.01) and clopidogrel (p = 0.02). White blood cells and admission glycemia were increased in STEMI (p = 0.001, respectively). The prevalence and severity of CAD was not different according to ACS types, but for a higher prevalence of thrombus (p < 0.001) and lower TIMI flow (p = 0.002) in STEMI. The levels of Lp-PlA2 were significantly lower in STEMI as compared to NSTE-ACS patients, (132 ± 41.1 vs. 154.6 ± 40.9 nmol/min/mL, p = 0.01). In fact, the rate of patients with Lp-PlA2 above the median (148 nmol/min/mL) was significantly lower in STEMI patients as compared to NSTE-ACS (32.3% vs. 57%, p = 0.02, adjusted OR[95% CI] = 0.20[0.06-0.68], p = 0.010). Moreover, a direct linear relationship was observed between Lp-PlA2 and LDL-C (r = 0.47, p < 0.001), but not with inflammatory biomarkers. The present study shows that among ACS patients, the levels of Lp-PlA2 are inversely associated with STEMI presentation and thrombotic coronary occlusion, being instead increased in NSTE-ACS patients, therefore potentially representing a marker of more aggressive chronic cardiovascular disease with an increased risk of recurrent cardiovascular events.

Characteristics and predictive factors of death in acute coronary syndromes among the elderly: data from the Acute coronary syndrome registry at the Abidjan Heart Institute

Acute coronary syndromes (ACS) are the leading cause of death among the elderly in sub-Saharan Africa. The aim of this study was to analyze the characteristics of ACS among the elderly at the Abidjan Heart Institute. Cross-sectional study from January 1, 2015, to December 31, 2019. All patients aged 18 or more admitted to the Abidjan Heart Institute for ACS were included. These patients were divided into two groups: elderly (≥ 65 years old) and non-elderly (< 65 years old). Clinical data, management and outcomes were compared and analyzed in both groups. A total of 570 patients were included, of which 137 (24%) were elderly. Sixty percent (60%) of elderly patients presented with ST Segment Elevation Myocardial Infarction (STEMI). Percutaneous coronary intervention (PCI) was less performed among elderly patients (21.1% vs 30.2%, p = 0.039). Heart failure was the most important complication among the elderly group (56.9% vs 44.6%, p = 0.012). In-hospital mortality was 8% among the elderly. Predictive factors for in-hospital mortality were history of hypertension (HR 2.58; CI95% 1.10-6.08) and STEMI presentation (OR 11.60; CI95% 2.70-49.76). PCI was a protective factor for in-hospital mortality (OR 0.14; IC95% 0.03-0.62). ACS occur with increasing frequency with age. Poor outcomes among the elderly are determined by the clinical presentation and comorbidities. PCI appears to significantly reduce in-hospital mortality.

Recovery From the Impact of COVID-19 on Treatment Times and Clinical Outcomes of Patients With ST-Segment Elevation Myocardial Infarction: An Interim Analysis

Previous studies have documented a negative impact of the COVID-19 pandemic on emergent percutaneous treatment of patients with ST-segment elevation myocardial infarction (STEMI), but few have examined recovery of healthcare systems in restoring prepandemic STEMI care. Retrospective analysis was performed of data from 789 patients with STEMI from a large tertiary medical center treated with percutaneous coronary intervention between January 1, 2019, and December 31, 2021. For patients with STEMI presenting to the emergency department, median time from door to balloon was 37 minutes in 2019, 53 minutes in 2020, and 48 minutes in 2021 (P < .001), whereas median time from first medical contact to device changed from 70 to 82 to 75 minutes, respectively (P = .002). Treatment time changes in 2020 and 2021 correlated with median emergency department evaluation time (30 to 41 to 22 minutes, respectively; P = .001) but not median catheterization laboratory revascularization time. For transfer patients, median time from first medical contact to device changed from 110 to 133 to 118 minutes, respectively (P = .005). In 2020 and 2021, patients with STEMI had greater late presentation (P = .028) and late mechanical complications (P = .021), with nonsignificant increases in yearly in-hospital mortality (3.6% to 5.2% to 6.4%; P = .352). COVID-19 was associated with worsening STEMI treatment times and outcomes in 2020. Despite improving treatment times in 2021, in-hospital mortality had not decreased in the setting of a persistent increase in late patient presentation and associated STEMI complications.

ST-segment elevation predicts the occurrence of malignant ventricular arrhythmia events in patients with acute ST-segment elevation myocardial infarction

BackgroundST-segment elevation (STE) represents a repolarization dispersion marker underlying arrhythmogenesis in ST-segment elevation myocardial infarction (STEMI); however, its value for predicting malignant ventricular arrhythmia events (MVAEs) remains uncertain.MethodsIn total, 285 patients with STEMI and those with or without MVAEs who presented within 6 h of symptom onset were enrolled. The relationships between STE and clinical characteristics of MVAEs (defined as ventricular tachycardia or ventricular fibrillation) were analyzed using t-test, chi-square test, binary multivariate logistic regression, and receiver operating characteristic curve analysis.ResultsPatients with STEMI and MVAEs had a shorter time from symptom onset to balloon time (p = 0.0285) and greater STE (p < 0.01) than those without MVAEs. The symptom-to-balloon time, age, and STE were associated with MVAEs after stepwise regression analysis in all cases. Only STE was significantly associated with the occurrence of MVAEs (all, p < 0.01). The area under the curve (AUC) of STE for predicting MVAEs was 0.905, and the cut-off value was 4.5 mV. When only infarct-related arteries were included in the analysis, the AUC of the left anterior descending artery was 0.925 with a cut-off value of 4.5 mV, that of the right coronary artery was 0.915 with a cut-off value of 4.5 mV, and that of the left circumflex artery was 0.929 with a cut-off value of 4.0 mV.ConclusionsIn patients with STEMI presenting within 6 h of symptom onset, age, symptom-to-balloon time, and STE were the main predictors for MVAEs. However, among these, STE was the strongest predictor for MVAEs and was an index for repolarization dispersion of cardiomyocytes in infarcted and non-infarcted areas.

101 LIPOPROTEIN ASSOCIATED PHOSPHOLIPASE A2 IN STEMI VS NSTE-ACS PATIENTS: A MARKER OF CARDIOVASCULAR ATHEROSCLEROTIC RISK RATHER THAN THROMBOSIS

Abstract Background The precise role of Lipoprotein associated phospholipase A2 (Lp-PlA2) in the pathogenesis of acute coronary syndromes (ACS) and in the prediction of future cardiovascular events is still debated. So far, few data exist on the variations of Lp-PlA2 activity in ACS and especially in NSTE-ACS vs STEMI patients, where thrombotic and atherosclerotic mechanisms could play a differential role. The aim of the present study was, then, to compare Lp-PlA2 activity according to the type of ACS presentation. Methods A consecutive cohort of patients undergoing coronary angiography for acute coronary syndrome (ACS) were included and divided according to presentation for non ST-segment elevation-ACS or ST-segment elevation Myocardial Infarction (STEMI). Lp-PLA2 activity was assessed on blood samples drawn at admission using the Diazyme Lp-PlA2 Activity Assay. Results We included in our study 117 patients, of whom 31 (26.5%) presented with STEMI. STEMI patients were significantly younger (p=0.05), displayed a lower rate of hypertension (p=0.002), previous MI (p=0.001) and PCI (p=0.01) and used less frequently statins (p=0.01) and clopidogrel (p=0.02). White blood cells and admission glycemia were increased in STEMI (p=0.001, respectively). The prevalence and severity of CAD was not different according to ACS types, but for a higher prevalence of thrombus (p&amp;lt;0.001) and lower TIMI flow (p=0.002) in STEMI. The levels of Lp-PlA2 were significantly lower in STEMI as compared to NSTE-ACS patients, (132±41.1 vs 154.6 ±40.9 nmol/min/mL, p=0.01). In fact, the rate of patients with Lp-PlA2 above the median (148 nmol/min/mL) was significantly lower in STEMI patients as compared to NSTE-ACS (32.3% vs 57%, p=0.02, adjusted OR[95% CI]=0.20[0.06-0.68], p=0.010). Moreover, a direct linear relationship was observed between Lp-PlA2 and LDL-C (r=0.47, p&amp;lt;0.001), but not with inflammatory biomarkers. Conclusion The present study shows that among ACS patients, the levels of Lp-PlA2 are inversely associated with STEMI presentation and thrombotic coronary occlusion, being instead increased in NSTE-ACS patients, and with recurrent cardiovascular events, therefore potentially representing a marker of a more aggressive atherosclerotic disease and higher cardiovascular burden and risk.

Differences in ST-segment Elevation Myocardial Infarction (STEMI) presentation and outcomes between 2019-2021 related to COVID-19

Background and Aims: COVID-19 accounted for 12.2% deaths in the United States between March 2020 and October 2021, while heart disease deaths increased by 4.1% from 2019 to 2020. Our study analyses the differences in STEMI presentation from 2019-2021 and the potential outcome differences for years related to the COVID pandemic. Materials and Methods: A five-site retrospective study included 1001 STEMI-activated patients from January 2019 to December 2021. Patient demographics, risk factors, details of presentation and rationale for cath-lab activation were obtained as presentation details. Discharge status, intraprocedural death, major bleeding requiring transfusion, CABG status and indication, and time variables were obtained to evaluate outcomes. Results: For 1001 STEMI-activated patients, risk factors were cerebrovascular accident (CVA), for 2019 versus 2020. New onset angina was significant in 2019 and 2021 versus 2020. Worsening angina was significant in 2019 versus 2020 as rationale. Patients were similarly discharged alive and required similar transfusion. CABG indications were similar, with no between-year differences. There were not differences in time variables for patients Discharged-alive but for patients Discharged-deceased, there was increased procedure to discharge and length of stay (LOS) for 2021 versus 2020. Also, patients Discharged-alive in all three years had shorter mean door-to-balloon (DTB) times than patients who were discharged-deceased in 2021. Discussion: For COVID-relevant years 2019-2021, patients had similar backgrounds for a STEMI-activated presentation. Patients were 1.84 times more likely to have history of CVA when they presented in 2019 versus 2020. New onset angina was higher in 2019 and 2021 and worsening angina was significant in 2019. Therefore, 2019 seemed to be more representative of typical angina presentation, compared to COVID peak 2020 and afterward to 2021. There was no increased rate of deaths attributed to STEMI hospitalization indicating that patients may have delayed to seek care, possibly attributed to the impact of the COVID lockdown or died at home related to cardiac event rather than seek medical care. For secondary outcomes, transfusion was equally likely. There were delays in procedure to discharge, LOS, and DTB times for 2021 versus 2020, which may be related to overall resource limitations.

Risk factors of contrast-induced nephropathy in patients with acute coronary syndrome

Patients with acute coronary syndrome (ACS) are at high risk of contrast-induced nephropathy (CIN), which is associated with prolonged hospitalization, higher morbidity and mortality after angiographic procedures. The occurrence of CIN is regarded as a transient and reversible condition. However, the persistence of CIN until hospital discharge in patients with ACS has not been thoroughly analyzed. We aimed to analyze CIN persistent until hospital discharge in contemporary ACS population referred to invasive diagnostics and treatment. A total of 2638 consecutive patients with ACS were included in a prospective registry. The occurrence of CIN was defined as a 25% increase in serum creatinine from baseline or a 0.5 mg/dl (44 μmol/l) increase in the absolute value. Criteria of CIN at hospital discharge were met in 10.7% of patients. Immediate percutaneous coronary intervention (PCI) after angiography (67% of patients) was associated with higher rates of CIN compared to patients referred for other treatment strategies (P < 0.001). The logistic regression model showed that anemia at baseline (8.7% of patients) was an independent predictor of CIN, which occurred in 17.9% of anemic patients and 10% of patients without anemia (P < 0.001). Also, ST-segment elevation myocardial infarction (STEMI) presentation and immediate PCI were independent predictors of CIN. Despite intravenous fluid administration during the hospital stay, CIN persisted until hospital discharge in more than 10% of patients with ACS. Anemia at baseline, STEMI presentation, and immediate PCI strategy were independent predictors of CIN. Thus, preventive actions should be specially aimed at those groups of patients.

North American COVID-19 Myocardial Infarction (NACMI) Risk Score for Prediction of In-Hospital Mortality.

BackgroundIn-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI) is higher in those with COVID-19 than in those without COVID-19. The factors that predispose to this mortality rate and their relative contribution are poorly understood. This study developed a risk score inclusive of clinical variables to predict in-hospital mortality in patients with COVID-19 and STEMI.MethodsBaseline demographic, clinical, and procedural data from patients in the North American COVID-19 Myocardial Infarction registry were extracted. Univariable logistic regression was performed using candidate predictor variables, and multivariable logistic regression was performed using backward stepwise selection to identify independent predictors of in-hospital mortality. Independent predictors were assigned a weighted integer, with the sum of the integers yielding the total risk score for each patient.ResultsIn-hospital mortality occurred in 118 of 425 (28%) patients. Eight variables present at the time of STEMI diagnosis (respiratory rate of >35 breaths/min, cardiogenic shock, oxygen saturation of <93%, age of >55 ​years, infiltrates on chest x-ray, kidney disease, diabetes, and dyspnea) were assigned a weighted integer. In-hospital mortality increased exponentially with increasing integer risk score (Cochran-Armitage χ2, P ​< ​.001), and the model demonstrated good discriminative power (c-statistic ​= ​0.81) and calibration (Hosmer-Lemeshow, P ​= ​.40). The increasing risk score was strongly associated with in-hospital mortality (3.6%-60% mortality for low-risk and very high–risk score categories, respectively).ConclusionsThe risk of in-hospital mortality in patients with COVID-19 and STEMI can be accurately predicted and discriminated using readily available clinical information.

Post Thrombolytic Angiographic Profile and TIMI Flow in Patients with ST-Elevation Myocardial Infarction

Background: Myocardial infarction (MI) is the leading cause of morbidity and mortality worldwide. Primary Percutaneous coronary intervention (PPCI) is recommended as a treatment of choice in patients with STEMI but fibrinolysis also remains prevalent as a reperfusion strategy in most of the patients with STEMI presenting to non-PCI capable hospitals where timely PPCI cannot be performed. Objectives: To assess the angiographic characteristics and angiographic success of thrombolysis in terms of TIMI 3 flow in patients who underwent angiography after thrombolysis for STEMI and the factors most commonly associated with unsuccessful thrombolysis. Methods: All 130 hospitalized patients in the department of Cardiology, at Bolan Medical Complex Hospital, Quetta from 31st July 2021 to 30th November 2021 with an acute ST-segment elevation MI (STEMI) diagnosis who received thrombolytics were included in this observational study. We didn't include patients who couldn't benefit from thrombolysis e.g. NSTEMI, contraindication to thrombolytics, and refused fibrinolysis. A 12-lead electrocardiogram (ECG) was performed when the patient arrived in ER and a repeat ECG was done 90 minutes after the administration of a thrombolytic agent (streptokinase). To assess the angiographic success of thrombolysis, coronary anatomy, and TIMI flow, we performed coronary angiography in all patients included in this study. Results: The study included 130 patients, 72 of whom had successful thrombolysis and 58 who had unsuccessful thrombolysis. Angiography reported TIMI 3 flow rates of 48(36.9%). Subjects in the unsuccessful thrombolysis group had the single-vessel disease in 29 (50%) and a multi-vessel disease was found in 19 (32.75%) of the patients. Patients with successful thrombolysis had Single vessel disease 6 (19.3%), Multivessel disease 1 (3.2) It was observed that patients with diabetes mellitus had a significant rise in the number of failed thrombolysis compared to those without diabetes mellitus (p&lt;0.005). It was also observed that anterior wall MI was significantly at risk for a failure in thrombolysis (82.1%) compared to inferior wall MI (17.8%). Conclusions: Effective thrombolysis was more prevalent than failed thrombolysis in our study. This data reiterates the utility of thrombolysis in resource-limited settings. Patients with diabetes, anterior wall MI, and delay in the presentations of the patients have a higher risk of thrombolysis failure. Type B lesions and multivessel disease were also prevalent in subjects with unsuccessful thrombolysis. According to the findings of this study, screening for risk factors before starting thrombolysis can aid in the development of alternative treatment methods that reduce failure rates and redirect resources to more successful treatment options. Keywords: Post thrombolytic; Angiographic Profile, TIMI flow; St-elevation; Myocardial Infarction

A randomized multicenter trial to evaluate early invasive strategy for patients with acute ST-segment elevation myocardial infarction presenting 24-48 hours from symptom onset: Protocol of the RESCUE-MI study

For ST-segment elevation myocardial infarction (STEMI) patients presenting 24 to 48 hours from symptom onset, whether early invasive strategy should be performed still remains controversial. This is a prospective, open-label, multicenter, investigator initiated, randomized controlled trial (NCT04962178) to evaluate the efficacy of early invasive strategy for STEMI patients within 24 to 48 hours of symptom onset. A total of 366 patients will be included from 10 hospitals in mainland China. They will be randomly (1:1) divided into 2 groups: the early invasive strategy group (primary percutaneous coronary intervention, PPCI) and conservative strategy group (optimal medical therapy with primary PCI not performed). All patients will be followed for 1 month. The primary end point is myocardial infarction size on cardiac magnetic resonance (CMR). The secondary end points are as follows: (1) major adverse cardiovascular events (MACE), which is defined as a composite of cardiac death, recurrent myocardial infarction, ischemic driven target vessel revascularization and stroke; (2) other CMR end points, including microvascular obstruction, intramyocardial hemorrhage, myocardial area at risk, left ventricular ejection fraction, left ventricular end diastolic volume and left ventricular end systolic volume. This study is designed to evaluate the efficacy of early invasive strategy for STEMI patients within 24 to 48 hours of symptom onset and will add more evidence for clinical practice. ClinicalTrials.gov Identifier: NCT04962178. Registered on July 14, 2021.

Trends in Clinical Presentation, Management, and Outcomes of STEMI in Patients With COVID-19

BackgroundWe previously reported high in-hospital mortality for ST-segment elevation myocardial infarction (STEMI) patients with COVID-19 treated in the early phase of the pandemic. ObjectivesThe purpose of this study was to describe trends of COVID-19 patients with STEMI during the course of the pandemic. MethodsThe NACMI (North American COVID-19 STEMI) registry is a prospective, investigator-initiated, multicenter, observational registry of hospitalized STEMI patients with confirmed or suspected COVID-19 infection in North America. We compared trends in clinical characteristics, management, and outcomes of patients treated in the first year of the pandemic (January 2020 to December 2020) vs those treated in the second year (January 2021 to December 2021). ResultsA total of 586 COVID-19–positive patients with STEMI were included in the present analysis; 227 treated in Y2020 and 359 treated in Y2021. Patients’ characteristics changed over time. Relative to Y2020, the proportion of Caucasian patients was higher (58% vs 39%; P < 0.001), patients presented more frequently with typical ischemic symptoms (59% vs 51%; P = 0.04), and patients were less likely to have shock pre-PCI (13% vs 18%; P = 0.07) or pulmonary manifestations (33% vs. 47%; P = 0.001) in Y2021. In-hospital mortality decreased from 33% (Y2020) to 23% (Y2021) (P = 0.008). In Y2021, none of the 22 vaccinated patients expired in hospital, whereas in-hospital death was recorded in 37 (22%) unvaccinated patients (P = 0.009). ConclusionsSignificant changes have occurred in the clinical characteristics and outcomes of STEMI patients with COVID-19 infection during the course of the pandemic.

The Impact of the Early COVID-19 Pandemic on ST-Segment Elevation Myocardial Infarction Presentation and Outcomes-A Systematic Review and Meta-Analysis.

Background: The influence of the early COVID-19 pandemic on non-COVID-19 emergencies is uncertain. We conducted a systematic review and a meta-analysis to evaluate the impact of the first months of the COVID-19 pandemic on the presentation, management, and prognosis of patients presenting with ST-segment elevation myocardial infarction (STEMI). Methods: We searched the PubMed, Scopus, and Embase databases from January to August 2020. A meta-analysis of studies comparing the profile, STEMI severity at presentation, reperfusion delay, and in-hospital mortality for patients presenting before and during the early COVID-19 pandemic was conducted. Fifteen cross-sectional observational studies including 20,528 STEMI patients from the pre-COVID period and 2190 patients diagnosed and treated during the first months of the COVID-19 pandemic met the inclusion criteria. Results: Patients presenting with STEMI during the pandemic were younger and had a higher comorbidity burden. The time interval between symptoms and first medical contact increased from 93.22 ± 137.37 min to 142 ± 281.60 min (p < 0.001). Door-to-balloon time did not differ significantly between the two periods (p = 0.293). The pooled odds ratio (OR) for low left ventricular ejection fraction at presentation during the pandemic was 2.24 (95% confidence interval (CI) 1.54–3.26) and for a presentation delay >24 h was 2.9 (95% CI 1.54–5.45) relative to before the pandemic. In-hospital mortality did not increase significantly during the outbreak (p = 0.97). Conclusion: During the first months of the COVID-19 pandemic, patients presenting with STEMI were addressed later in the course of the disease with more severe left ventricular impairment. In-hospital emergency circuits and care functioned properly with no increase in door-to-balloon time and early mortality.

806 Scout post-PCI instantaneous wave-free ratio as a driver of functional complete

Abstract Aims Physiology assessment by means of instantaneous wave-free ratio (iFR) is non-inferior to fractional flow reserve for the assessment of intermediate coronary lesions that are candidates to percutaneous coronary intervention (PCI). However, in pivotal trials assessing iFR, tandem coronary lesions (i.e. two serial lesions located in the same coronary artery) were excluded. In addition, the role of iFR after PCI as a way to optimize its success is poorly understood, particularly in the context of ST-segment elevation myocardial infarction (STEMI) with multivessel disease and tandem stenoses. We describe an illustrative case of post-PCI iFR in a STEMI patient with multivessel disease that led to a significant change in the revascularization strategy. Methods A 71-year old man presented with infero-lateral STEMI and received PCI with 1 drug-eluting stent (DES) 2.25 × 18 mm on the distal right coronary artery. The left coronary artery presented a 30–40% stenosis of the proximal left circumflex (LCX) and a 90% bifurcation stenosis of the mid portion of the same artery. PCI of the distal lesion was performed with implantation of 1 DES 3.0 × 22 with flaring of the stent at the level of the side branch and proximal optimization technique. Post-PCI iFR of the LCX was performed to assess the success of the procedure, with a value of 0.74. To understand the relative contribution of the two tandem stenoses, a pullback of the iFR wire was performed, which showed an unexpectedly small jump of the pressure when the wire was between the two lesions (0.80). Results As such, the significant contribution of the proximal lesion was unravelled, which led to implantation of a second DES 4.0 × 26 mm, partially overlapping with the previously implanted DES. Post-PCI iFR confirmed the complete success of the procedure (1.00). Conclusions In the context of complete revascularization for STEMI presenting with non-infarct related artery tandem stenoses, post-PCI physiology contributes to unravel the relative contribution of low-grade angiographic stenoses corresponding to functionally significant atherosclerosis left untreated. This case example illustrates the emerging procedural value of post-PCI iFR in achieving the goal of complete functional revascularization.

Cardiogenic shock in patients presenting with acute left main coronary artery occlusion

Abstract Background and purpose Acute myocardial infarction (AMI) due to left main coronary artery (LMCA) occlusion is a rare event, often catastrophic. Limited data are available about management and outcomes of patients with acute LMCA occlusion, including those presenting with cardiogenic shock (CS) at hospital admission. This study sought to describe patients with AMI due unprotected LMCA occlusion presenting with CS and to evaluate their in-hospital outcomes and 1-year mortality. Methods In this retrospective 2-center study, we identified 7630 patients with ST-segment elevation myocardial infarction (STEMI) or hight risk non-ST segment elevation myocardial infarction who underwent to emergent coronary angiography between January 2008 and December 2020. Among this cohort, we analysed 94 patients who presented with unprotected LMCA occlusion (Thrombolysis In Myocardial Infarction – TIMI ≤2) and divided them in 2 groups according to presence of signs of cardiogenic shock at admission: CS and no-CS. Results Of 94 patients with AMI due LMCA occlusion, 52 patients presented with CS (53.3%). Mean age was 62.8±11.5 years in CS and 62.0±15.9 years in no-CS patients, p=0.766. In both groups, most patients were male. STEMI presentation was more frequent in CS group (80.4% vs. 52.4%, p=0.004). Severe systolic dysfunction of left ventricle was more frequent in CS patients (81.1% vs. 33.3%, p&amp;lt;0.001). Compared to no-CS patients, CS group shown more often TIMI=0 (67.3% vs. 26.2%, p&amp;lt;0.001), collateral coronary circulation Rentrop 0–1 (95.3% vs. 75.0%, p=0.008), and slow-reflow/no-reflow phenomena (30.6% vs 3.8%, p=0.019) in emergent coronary angiography. The need of invasive mechanical ventilation (68.9% vs. 21.4%, p&amp;lt;0.001), and haemodialysis (20.5% vs. 2.4%, p=0.010) were more prevalent in CS patients. Likewise, mechanical circulatory support (MCS) was more frequently used in patients presented with CS (52.9% vs. 26.2%, p=0.009). In subgroup analysis, MCS implantation was not a survival predictor in CS patients (Odds ratio: 3.9 [95% confidence interval: 0.4 to 36.3], p=0.229). Ultimately, in-hospital mortality (78.8% vs. 16.7%, p&amp;lt;0.001) was higher in CS patients. On the other hand, in hospital survivors, there was no significant differences in 1-year mortality (11.1% vs. 23.5%, p=0.42) between both groups. Conclusions Nearly half of patients with AMI due LMCA occlusion presented with CS signs at first medical evaluation. This subgroup of patients had higher in-hospital mortality compared to those without CS, despite MCS implantation. Whether the use of a specific MCS device or whether early use of MCS can change the outcome remains to be elucidated. CS patients who survive to index-hospitalization, had similar long-term outcomes compared to no-CS patients. Further studies are imperative in this population to refine initial medical treatment in order to improve their prognosis. Funding Acknowledgement Type of funding sources: None.